Hepatitis C and Innovative Public Health Practice

Transcription

1 Hepatitis C and Innovative Public Health Practice Ann Thomas MD, MPH Ann Shindo, PhD, MSW, MPH, MS Oregon Public Health Division

2 Prevalence of anti-hcv Prevalence of Anti-HCV* (US, NHANES**) Overall prevalence 1.6% 2.7 million Americans chronically infected 8% 7% 6% 5% 4% Men Women 48,000 Oregonians chronically infected 3% 2% 1% * Hepatitis C Virus 0% All ** National Health and Nutrition Examination Survey Age Group (years) Source: Armstrong Ann Intern Med 2006;144:

3 Estimated Incidence of Acute HCV (US, ) Surrogate testing of blood donors Anti-HCV test (first generation) licensed Anti-HCV test (second generation) licensed Source: CDC Sentinel Counties Study of Acute Viral Hepatitis

4 Question The biggest challenge in addressing HCV in my jurisdiction is: A. Health providers' ignorance B. Lack of resources for follow-up of cases C. Lack of public awareness regarding the HCV epidemic D. Stigma associated with HCV Click on the down arrow if you can t see the response choices.

5 HCV: Clinical Features Incubation period: Clinical illness: 30 40% Jaundice 20 30% Anorexia, malaise, 10 20% or abdominal pain Virus detectable 1 2 weeks Antibodies 7 8 weeks Typical course: Asymptomatic for decades

6 Risk of Fatal Outcome in Persons Who Develop Hepatitis C Infection Time Resolve % 85% Courtesy of Seeff, LB and Alter, HJ.s Chronic 85 80% 20% Stable 68 Stable 13 Cirrhosis 17 75% 25% Mortality 4

7 Risk of Fatal Outcome in Persons Who Develop Hepatitis C Infection 48,000 Oregonians Time Resolve % 85% Courtesy of Seeff, LB and Alter, HJ.s Chronic 85 80% 20% Stable 68 Stable 13 10,000 Cirrhosis 17 75% 25% 1,000 2,000 Mortality 4

8 Costs of HCV Nationally (1997 data) $5.46 billion 33% direct 67% indirect Comparison: asthma, $5.8 billion spent in 1994 HCV costs expected to double or triple by Oregon Medicaid fee-forservice patients (2007 data) Medication costs=$400,000 (doesn t include office visits, dx testing, biopsies) OHSU performs 25 transplants for HCV annually, cost for first year = $300,000 Source: Leigh Arch Int Med 2001, 161: ; Oregon DHS OMAP, personal communication

9 Reported Risk Factors for Acute HCV Infection, Oregon, , n = 47 Other** High Risk Sex 5% 10% *PWID: Persons Who Inject Drugs **Other: Tattoo, pierced, employed in medical field Unknown 22% 63% PWID*

10 Seroprevalence (%) Risk of HCV, HBV,* and HIV Infection Among Persons Who Inject Drugs (PWID) HCV Baltimore HBV HIV Duration of Injecting (mo) * Hepatitis B Virus Garfein RS. Am J Public Health. 1996;86:655.

11 Percent Hepatitis C and HIV in Persons Who Inject Drugs, Oregon State Penitentiary, Hep C HIV Source: Public Health Division, Oregon DHS

12 Prevalence of HCV, HBV, and HIV in Persons Dying of Injection Drug Overdose* Number Positive/ Number Tested Percent HIV 3/97 3 HCV 68/94 72 HBV 30/84 36 HCV/HIV 1/84 1 HBV/HIV 0/84 0 HBV/HCV 26/84 33 All three 2/84 2 *Oregon, Nov Dec Source: Public Health Division, Oregon DHS

13 Percent (%) Positive Prevalence of HCV Overall, 317/936 (32%) persons tested were HCV+ Most important risk factor identified was injection drug use 0 Overall PWID Multnomah County Screening Program, 2000 Source: Public Health Division, Oregon DHS

14 Prevalence of HCV in Different Risk Groups Among Non-PWIDs Number Positive/ Number Tested Percentage History of STI* 8/157 5 MSM** 2/187 1 Multiple sex partners 5/221 2 Exchanged sex for money or drugs 1/23 4 * Sexually Transmitted Infections ** Men who have sex with men Source: Multnomah County, 2000

15 Question Prevalence of hepatitis C among Persons Who Inject Drugs (PWID) is higher outside the Portland-Metropolitan area: A. True B. False Click on the down arrow if you can t see the response choices.

16 Multnomah County HCV Registry Study, % sample of patients with lab-confirmed HCV reported to Multnomah County Health Department (MCHD) Contacted provider to obtain assent to contact patient* In-person or phone interview Demographics, risk factors, medical history, ability to access health care, addiction, and mental health issues Enrollment = 25% *Except if patient is seen in ED, inpatient, occupational health, blood bank, or outreach

17 Demographic Characteristics of Enrolled Subjects, n = 196 Education 50% with > high school education Income 80% < $30,000 Homeless 25% homeless in past year Insurance 37% with Medicaid 24% uninsured

18 Addiction Issues 94% currently drinking alcohol 17% felt should cut down on drinking 10% felt guilty about drinking 10% had morning eye-opener 80% had ever injected drugs 21% injected in past year

19 Mental Health Issues Over 60% were diagnosed/treated for mental health issues (self-report) Of 86 who completed: Beck Depression Inventory 30% met criteria for major depressive order Mood Disorder Questionnaire 13% positive for bipolar disorder

20 Pilot HCV Seroprevalence Activities 15 participating counties 2520 free HCV tests available Targeted HCV testing based on increased risk for infection 583 tests performed 128 (22%) anti-hcv positive specimens

21 Number of cases Sex and Age Among HCV Positive Cases, n = Men Women s 30s 40 and up Age group

22 Race Among Anti-HCV Positive Cases, n = 128 Mixed 2% Black 2% Asian 1% Unknown American Indian/ Alaska Native 6% 5% 84% White

23 Question Do you or some other division of your agency encounter persons who may be at risk for HCV during the course of daily work? A. Yes B. No Click on the down arrow if you can t see the response choices.

24 Prevalence of HCV Among PWID in Oregon, 2007 % Rural Population Percent HCV + Marion 15% 20% Benton 19% 40% Lane 19% 38% Jackson 22% 21% Umatilla 30% 35% Klamath 36% 21% Linn 37% 33% Deschutes 37% 31% Coos 38% 17% Douglas 42% 15% Total 27% NEX* * Needle Exchange

25 Summary Surveillance nightmare Incidence declining, difficult to measure Large burden of chronic disease Prevalence in PWID much higher than for HIV Concomitant psychosocial issues present huge barriers to diagnosis and management

26 HCV Innovations Federal picture State picture Innovative program example More we can do?

27 Domestic HIV, Viral Hepatitis, STI, and TB Prevention Appropriated Funds TB Hepatitis 2% Total: $963.1 million 14% STD 16% 68% Domestic HIV *Fiscal Year 2006 **Source: CDC

28 HCV and Public Health Interventions: Federal Focus National Center for HIV, Hepatitis, STD, TB Prevention (NCHHSTP) Program Collaboration Service Integration (PCSI)

29 PCSI

30 Question Which of the following are ways you could provide support to integration of HIV/viral hepatitis/std service delivery in your agency? A. Collaborate with managers in other divisions B. Cross-train staff to support integrated work activities C. Develop low-impact methods of one-stopshop public health interventions that work for our diverse service delivery programs D. All of the above

31 PCSI Bottom Line One-stop-shop for core public health services for persons at risk for HIV, viral hepatitis, STDs, and TB HIV, Hepatitis, STD Say it like it s one word!

32 HCV and Public Health Interventions: State Focus Surveillance Programs HCV screening Hepatitis A/B vaccine to high-risk adults Integration with HIV, STI, TB (when appropriate) Targeting the highest-risk adults in Oregon

33 Innovative Approaches Example: Marion County, Oregon Marion County STI routinely clinic screens for hepatitis vaccine for adults Vaccines are administered by immunization nurses at time of STI appointment On-demand HIV and HCV testing are provided through the HIV prevention section

34 Outcomes June 2004 through October client records tracked in study log Age = % had insurance that could be billed 89% of vaccine eligible clients received verbal recommendation from nurse provider 64% received vaccine

35 Supports to Integrated Service Delivery Close proximity of services (STI next door to Immunology, HIV prevention down the hall) Sticker tickler system Pre-project communication and brainstorming Cross-training of administrative, nursing, and health education staff

36 Barriers to Integrated Service Delivery Remembering to screen each client at STI clinic (administrative) Unknown if single antigen or Twinrix indicated (administrative) Vaccine Administration Record completion (nurse) Learning new vaccine protocols (nurse)

37 Innovative Approaches Example: HIV Alliance, Eugene, Oregon NEX outreach van 1 x per week under bridge in semi-rural area: Medical provider: wound care Nurse practitioner: Twinrix A/B vaccine HCV screening: home access kits HIV testing: Orasure Referral services to actual people, not just agencies

38 Feasibility of PCSI in Oregon Local Health Departments Very feasible if just one person willing to be the shameless instigator to instigate integration Precedent set in urban and rural settings Cross-training of staff is necessary given ongoing public health budget cuts in Oregon (e.g., timber fund cuts)

39 Bottom Line of HCV Innovation: Moving Past Our Silo-ized PH Delivery Systems! The only way to address the HCV epidemic is through integrated service delivery options like comprehensive services at LHDs and holistic health services through NEX programs. Test! Educate! Vaccinate!

40 Barriers to Medical Intervention Barriers Micro Meso Macro HCV + Individual Seeking Treatment Mental health Substance use Social support Housing CAM A/B vaccines Stigma Health policies Federal funding streams Drug- Based Therapies